Surgical Treatment Of Essential Tremors
When medications are not effective, one additional option is surgery to destroy the abnormal brain cells that are responsible for the tremors. These cells are located deep in the brain in the thalamus in a bilateral structure called the basal ganglia. There are several nuclei in the thalamus, but the one that is related to tremors is called the ventral intermediate nucleus . The operation, thalamotomy, can be done by conventional stereotatic surgery or by the use of a Gamma knife . Since there is one thalamus in each side of the brain, the thalamotomy could be unilateral or bilateral. An additional option is by deep brain stimulation with implanted electrodes.
These techniques have proved to be very effective in some patients but are not free of side effects. At the present time the following are accepted recommendations:
What Are The Symptoms And Signs Of Hand Tremors And Types
Two main categories can be recognized:
The normal or physiological tremor is a fine, almost imperceptible, tremor that is difficult to see by the naked eye and does not interfere with activities. It can be seen in the fingers when the arms are outstretched. The frequency of the contractions is in the area of 8 to 13 cycles per minute. The cause of this tremor is not known, but it is not considered to be associated with any disease process.
The abnormal or pathological tremor it is more obvious and more visible to the naked eye. As such, it does interfere with everyday activities. The frequency of the contractions is in the area of 4 to 7 cycles per minute. In many instances this tremor is associated with defined medical conditions.
Most often the abnormal tremor is observed in the distal parts of the limbs however, every part of the body can be affected by the tremor.
The clinical distribution of the tremor might be different depending upon the medical condition associated with it and some individual factors. However, in a particular individual the quality and distribution of the tremor is very constant.
These abnormal tremors can be subclassified into the following categories:
This type of tremor is seen most often, among other conditions, in persons with multiple sclerosis.
Hand And Wrist Exercises
Your healthcare provider may refer you to a physical or occupational therapist for treatment or recommend exercises you can do at home.
Squeezing a stress ball or hand grip for two to 10 seconds, releasing, and repeating 10 times on each hand can be an easy exercise to incorporate into your day.
Rotating the wrists in a circular motion can keep tendons and ligaments flexible. Moving the hands with intention can keep synovial fluid from building up, which prevents or reduces tremors.
Curling a light hand weight with arms resting on a table and your palms facing up can also strengthen and fine-tune your muscle control.
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How Tremors Impact Function And What You Can Do About It
When we are toddlers we are constantly problem-solving how to accomplish a task and creating neural pathways that become stronger with each repetition. As adults our brains are wired to accomplish the task without thinking about it. We put our jacket on in the same way everyday. When you experience tremors, suddenly the way youve always done something doesnt work. Its incredibly frustrating! But there are so many ways to accomplish a task and learning to modify your movements, your environment, or the activity itself can provide great satisfaction and improved quality of life.
Begin to build the habit of asking yourself some questions:
What can I change about the actual task?What can I change about the environment?What can I change in myself to accomplish the task?
People who experience resting tremors might have difficulty with activities that require fine motor skills, such as handwriting, buttoning buttons, zipping zippers, handling money, etc.
Is there a pen that you can use to help write? Try something thicker, heavier, or a different ink. Does it help to support your arm on a surface or closer to your body? Does it help to sit or stand? Can you use voice recognition software? What accessibility options are available on my smartphone or computer?
Can you wear clothes that dont have fasteners? Can you pull the fabric over a button instead of pinching the button? Can you use a key ring on a zipper to help pull it up?
Clinical Conditions Associated With Tremors
Familial and Essential Tremor
Familial and essential tremors are the most common conditions associated with action tremor. In the familial, or hereditary form, several members of the same family are affected. This is a genetically heterogeneous condition, and more than one gene might be involved.
The non-familial form is referred to as essential tremor because it is not associated with any other neurological condition. The term “benign essential tremor” has been used in reference to this tremor however, this is misleading since the tremor can be very severe and disabling. The essential and the familial hereditary forms are similar in clinical presentation.
There is no diagnostic test that confirms the condition. The diagnosis is based on clinical findings. However some tests might be indicated to rule out other conditions.
This type of tremor is predominant in the Parkinsonian syndrome
The better known of these conditions is Parkinson’s disease, a degenerative progressive disorder of the brain that predominantly affects a deep structure of the brain called the substantia nigra, located in the basal ganglia. The cause of the disease is unknown, the strongest associated risk factor being age. In some individuals, genetic factors might be important.
In Parkinson’s disease the tremor is the most common initial sign. This is followed by:
Other conditions with Parkinsonian Tremors
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How Is Essential Tremor Diagnosed
The appearance of your tremor, in the setting of a comprehensive neurological examination by an experienced clinician, can result in diagnosis of essential tremor. Your doctor will probably need to rule out other conditions that could cause shaking or trembling. For example, tremors could be symptoms of diseases such as hyperthyroidism. Your health care provider might test you for those as well.
In some cases, the tremors might be related to other factors. To find out for certain, your health care provider may have you try to:
- Abstain from heavy alcohol use trembling is a common symptom among people with alcohol use disorder.
- Avoid caffeine.
- Avoid or reduce certain medicines.
Causes Of Essential Tremor
The exact cause of essential tremor is unknown, but essential tremors tend to occur when there are nerve-related problems that influence the muscles with which they are connected. Research has also indicated that the part of the brain that controls the movement of muscles may not function properly in patients with essential tremor. In some cases, several family members may have essential tremor, known as familiar tremor and it is believed to be caused by a genetic mutation.
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Consider Tremor Along With Other Symptoms
Parkinsons reputation is that it is a tremor disease, and thats how you can identify it across a crowded room, says Rebecca Gilbert, MD, PhD, chief scientific officer for the American Parkinson Disease Association in New York City.
Although tremors bring people to diagnosis in many cases, defining the condition as a tremor disease may have done patients a disservice over the years because there are more severe symptoms that people struggle with. Tremor is just the one that people can see, according to Dr. Gilbert.
Many think if you dont have a tremor everything is fine, she says. That isnt true.
Over time, other disease features, such as cognitive problems, psychosis, blood pressure irregularities, depression, and lack of desire to do things, can be more devastating.
James Beck, PhD, chief scientific officer with the Parkinsons Foundation, also cautions that tremor may not be the first distinguishing feature.
A person may notice a slowness of movement called bradykinesia, he says. Or someone may be walking down the street and one arm doesnt swing. These symptoms may appear before tremor.
While focusing only on tremor may not be advisable, understanding this abnormal movement and treatment options may help patients improve their quality of life.
Speak With Your Doctor About Treatments
If youve experienced shaky hands or symptoms of essential tremor, make an appointment to speak with your doctor. They will likely request several medical and physical tests to rule out other possibilities before a diagnosis can be made.
Once a diagnosis is made, you can begin to discuss treatment options. Treatment may not be necessary if the tremor is mild and doesnt interfere with day-to-day activities.
If the shaking becomes too difficult to manage, you can revisit the treatment options. Finding one that works well with minimal side effects may take time. You can work with your doctor and any therapists or specialists you visit to find a plan that best suits your needs.
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Other Tremors And How It Differs
A Parkinsonian tremor has a few distinct characteristics, though it may be easy to confuse with other types of tremors depending on the other symptoms a person shows. Doctors will look for and rule out other types of tremors to confirm their diagnosis.
The National Institute of Neurological Disorders and Stroke notes that some common tremors include:
The Right Diagnosis Can Save Time
Because the symptoms of Parkinsons vary and often overlap other conditions, it is misdiagnosed up to 30% of the time, Dr. Fernandez says. Misdiagnosis is even more common in the early stages.
Patients who dont know where to turn may make appointments with a rheumatologist, or an orthopaedic or heart specialist, and undergo MRIs, EMGs and other expensive tests.
But only a neurologist can distinguish Parkinsons from essential tremor, drug-induced Parkinsons and Parkinsons plus syndromes, he says.
If patients come to us with typical signs of Parkinsons, we dont need to order expensive tests, he says.
Instead, neurologists base their diagnosis on a detailed patient exam and medical history, along with other information from the patient, family members or caregivers.
Thats all stirred into the pot, he says. Sometimes we can diagnose Parkinsons with one visit. Other times, several follow-up visits are necessary.
Medical Treatment Of Parkinson’s Disease
Levodopa/carbidopa is the most effective medication in terms of improving the motor symptoms associated with Parkinson’s disease. However due to the frequent, and sometimes serious side effects of this drug, neurologists prefer trying other medications first. Unfortunately, the medications available are not as good as levodopa/carbidopa in the control of the motor symptoms and also have some side effects that limit their use.
Selegiline a medication that does not have any major effects on the motor symptoms, might be the only medication with some protective effect of the nerve cells, but this is not yet well proven. The other medications are only used to treat the symptoms.
Characteristics Of Pd Tremors
The tremors of PD characteristically occur at rest, stop with voluntary action, and recur again after you hold your new position for a few minutes. PD tremors can affect the hands, arms, face, jaw, legs, and/or feet, and are often slightly more prominent on one side than the other.
The tremor almost always begins in the hand before affecting other parts of the body, and it usually looks like you are rolling a pill between your thumb and index finger. Thats why its called a pill-rolling tremor.
A pill-rolling tremor is the most common type of PD tremor, but shaking tremorswhich may involve the hands or other areas of the bodycan also occur.
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Parkinsons Tremors Vs Essential Tremors
Because they can be similar to Parkinsons tremors, essential tremors are often confused as symptoms of the disease. Just as with Parkinsons, essential tremor can cause uncontrollable rhythmic shaking in different parts of the body.
Up to 10 million people are affected by this common nervous system disorder. While genetics and environment likely play a role in essential tremor, the cause is unknown, according to the U.S. National Library of Medicine.
Essential tremors in the hands or arms can be distinct from Parkinsons because they typically happen when the hands are in use.
The essential tremor can get really bad when youre using your limb when drinking or eating soup, for example, says Gilbert. The Parkinsons tremor is usually not as disabling whereas the essential tremor can be life-altering.
The shaking from an essential tremor typically improves when using both hands to bring a cup to the mouth but the same action can amplify the tremor in Parkinsons, according to Gilbert.
Dr. Beck points out that an essential tremor may be faster than a Parkinsons tremor, which tends to be milder. A difference can often be seen in a persons handwriting. Those with essential tremor tend to have more unsteady and wavy writing, whereas Parkinsons patients are more apt to display micrographia, or abnormally small handwriting.
They have low amplitude movement so their writing gets smaller and smaller to a point where it can be barely legible, he says.
Cognitive And Psychological Differences In Patients With Essential Tremor
Benign essential tremor is probably the most common of all movement disorders. Someone with essential tremor has increased shakiness, usually of the hands or arms, whenever the limb is being used.?? This distinguishes the tremor from that of classical Parkinsons disease, which is usually worse when the arm and hand are at rest.
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How Is Tremor Treated
Although there is no cure for most forms of tremor, treatment options are available to help manage symptoms. In some cases, a persons symptoms may be mild enough that they do not require treatment.
Finding an appropriate treatment depends on an accurate diagnosis of the cause. Tremor caused by underlying health problems can sometimes be improved or eliminated entirely with treatment. For example, tremor due to thyroid hyperactivity will improve or even resolve with treatment of thyroid malfunction. Also, if tremor is caused by medication, discontinuing the tremor-causing drug may reduce or eliminate this tremor.
If there is no underlying cause for tremor that can be modified, available treatment options include:
A new treatment for essential tremor uses magnetic resonance images to deliver focused ultrasound to create a lesion in tiny areas of the brains thalamus thought to be responsible for causing the tremors. The treatment is approved only for those individuals with essential tremor who do not respond well to anticonvulsant or beta-blocking drugs.
When people do not respond to drug therapies or have a severe tremor that significantly impacts their daily life, a doctor may recommend surgical interventions such as deep brain stimulation or very rarely, thalamotomy. While DBS is usually well tolerated, the most common side effects of tremor surgery include dysarthria and balance problems.
Box 3 Clinical Features Suggestive Of Psychogenic Tremor73
Tremor increases with attention, and lessens with distractibility
Responsive to placebo
Absence of other neurological signs
Spontaneous remissions or cures of symptoms
No evidence of disease by laboratory or radiological investigations
Employed in allied health professionals
Litigation or compensation pending
Presence of psychiatric disease
Reported functional disturbances in the past
Commonly, patients with psychogenic tremor often undergo a large number of diagnosis and therapeutic procedures before the final diagnosis is established. A review of medical history in these patients usually shows multiple functional somatic or psychosomatic illnesses. Once the diagnosis is made, most patients continue to have a fluctuating or constant course, followed by improving and progressive periods suggesting the prognosis is far from benign. The therapeutic success is also variable, but the treatment approach should include various combinations of psychotherapy as well as drugs, such as mild anxiolytics and antidepressants. While pharmacological treatment in organic tremor may reduce amplitude, but does not change the tremor frequency, the effect of treatment in psychogenic tremor usually varies from total suppression of tremor, especially when associated with the suggestion of a cure to no benefit. Interestingly, most of successfully treated patients were young.
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Tremor And Loss Of Physical Control In Parkinsons Disease
Often, the first symptoms of Parkinsons disease to appear are in the upper limbs. People had discovered there were things that they had always done without a second thought, like opening a door or combing their hair, that for some reason they now have difficulty doing or may not be able to do at all. What they cant understand is why they can no longer do them. As Natalia described it, To move papers around, the message doesnt get to my hands and my brain doesnt give the message what to do. Khadim said it felt as though someone was pulling at his hand stopping him from moving it.
Tremors Definition And Facts
Tremors are non-intentional rhythmic movements of a body part, which are the result of alternating or irregular synchronous contractions of muscles that have an opposite effect on a joint. For example, muscles that, when contracted, result in flexion of the wrist are stimulated synchronously with muscles that result in extension of the wrist. The result is a rhythmic flexion and extension of the wrist.
- This phenomenon can happen in any part of the body including: head, neck, face, thumb, or arm.
- It is this rhythmic quality that defines and distinguishes tremors from any other abnormal movements.
- Two tremors classes including: physiologic and pathologic
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Tremors May Be Nothing To Worry About Or Something More Serious But Don’t Let Them Go Unchecked
Do you ever notice that you can’t seem to hold a coffee cup still? Or that your hands sometimes tremble so much it interferes with daily chores? Those involuntary hand movements are called tremors. “They’re common in middle and older age,” says Dr. Chizoba Umeh, a neurologist who specializes in movement disorders at Harvard-affiliated Brigham and Women’s hospital. “They’re not life-threatening, but people with severe tremors may have a hard time feeding themselves, dressing, or driving.”